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How Ethiopia Improved the Quality of Maternal Care Through the Strengthening of Midwifery Training

By Metasebia Dereje and Beti Baiye

The thrill and anticipation of becoming a new mother is universal and the life of every pregnant woman matters. No woman should lose her life, because she is giving life, no matter where she lives and regardless of her income. This is why the unacceptably high ratios of maternal mortality in Sub-Saharan Africa is a major public health challenge.

Ethiopia’s maternal mortality rate currently stands at 401 for every 100,000 live births, a reduction from 676 for every 100,000 live births in 2011. While this reduction is positive news, it remains higher than SDG target 3.1, calling for a reduction in the MMR to less than 70 per 100,000 live births. This decline in the maternal mortality rate can, in part, be attributed to the innovative programmes designed to expand and accelerate midwifery training to achieve a minimum standard of midwife to population ratio and increase skilled birth attendance and reproductive health services, especially in the rural areas. The programmes are also narrowing the gap in health service delivery and strengthening the midwifery profession in Ethiopia. An example is the United Nations Population Fund (UNFPA) Accelerated Midwifery Programme and the U.S. Agency for International Development (USAID) led Strengthening Human Resources for Health (HRH) project.

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More than just assisting with childbirth

Midwifery is more than just about assisting childbirth. It is that and so much more. A 2014 Lancet Series on Midwifery defined it as “skilled, knowledgeable, and compassionate care for childbearing women, newborn infants, and families across the continuum throughout pre-pregnancy, pregnancy, birth, post-partum, and the early weeks of life”. Knowledge of correct prenatal care, skilled delivery, and postpartum care is crucial for the survival of mothers and their babies. The series revealed that interventions implemented by the midwifery workforce could reduce maternal and newborn deaths and stillbirths in low-income and middle-income countries (LMICs) by 30–80%, depending on the level of intervention coverage.

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According to Tigist Gudeta, a midwife at Zewuditu Memorial Hospital, Addis Ababa, “Being a midwife is not just helping mothers during labor but helping them before and after giving birth and we developed the skills through trainings”.

A recent study into the potential impact of midwives in reducing maternal and neonatal mortality also revealed that a substantial increase in coverage of midwife-delivered interventions could avert 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths, equating to 2.2 million deaths averted per year by 2035.

A government policy

In 2012, the government of Ethiopia implemented urgent policy decisions that encouraged anyone who was interested in becoming a midwife to study in universities and other training centers. “This helped solve the problem of the uneven distribution of midwives,” said Zenebe Akale, maternal case team officer and board member of Ethiopian Midwives’ Association, established in 1992 and currently with 8200 registered members.

People interested in becoming midwives could choose from any of these qualifications: Bachelor’s degree, Diploma, and accelerated midwives. The Bachelor’s degree is a four-year training programme, post-secondary school, the diploma is a three-year programme of specialised midwifery training, and the accelerated training is a three-year programme of nursing and one year of midwifery training. There are 46 training institutions across Ethiopia, 18 offer bachelor degrees and the rest provide basic training or diploma level training. Today, all regions except for Gambella have midwifery training institutions.

In 2009, there were 1200 midwives in Ethiopia, which, based on the nation’s population at the time, was a ratio of one midwife to 57,000 people. By 2015, the number of midwives had increased to 7800, resulting in a ratio of one midwife to 10,500 people. Although this is nothing close to the 4.5 per 1000 population standard proposed by the World Health Organization (WHO) to achieve Universal Health Coverage (UHC), it is still work in progress. The Ministry of Health (MoH) with support from the UNFPA helped train 4500 midwives. The next step was to train an additional 9,866 midwives by 2020.

Midwives can provide 87% of essential care and with increased investment — which could strengthen the primary healthcare system and provide a pathway to UHC — they could prevent over 80% of all maternal deaths, stillbirths, and neonatal deaths. Photo credit: Metasebia Dereje

An incredible resource

One major goal of the expansion of the midwifery training programmes is to grow the number of skilled midwives available in the country in order to deploy them to rural areas, and to have at least two midwives at each primary health center throughout the country. This would be an incredible resource for the women living in rural areas who are unable to access skilled healthcare workers, especially considering that midwives can provide 87% of essential care and with increased investment — which could strengthen the primary healthcare system and provide a pathway to UHC — they could prevent over 80% of all maternal deaths, stillbirths, and neonatal deaths.

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In the past, mothers didn’t have midwifery services close to them and so they were forced to travel long distances to health centers that had midwifery services. But now, they can easily access the service in a health center close to them. “These days mothers do not prefer giving birth at home like previous times, because they can easily get the help of midwives around them,” said midwife Tigist.

Mrs. Mulu, a mother of three said that when she gave birth to her first child 12 years ago, people warned her not to go to government health centers because there were not enough health workers, and she wouldn’t receive proper treatment. When she decided to go, even though she was in labour and at risk, she said she had to wait for hours to enter the delivery room. There were a lot of women giving birth and not enough hands. Fortunately, she and her infant survived but many women may have died as a result of this delay. “But today, there are nurses (midwives) who follow your labor and give you immediate service when needed,” Mulu added in relief.

Overall, although the country still has a long way to go, the expansion of midwifery training programmes and the quality of training received, as well as the growing number of midwives throughout Ethiopia has greatly contributed to a decrease in the country’s maternal mortality and infant mortality rates (currently at 47 deaths per 1,000 live births). According to the Ministry of Health, more than 20,000 midwives have been deployed to health centres across the country. Every year, newly trained midwives join the profession and the perception of what they can do is changing because midwives are trained in first, second and even third degrees from recognised institutions. As a result, mothers are now more trusting and frequently visit health care centers. Also, since midwives became more accessible, the number of mothers referred to other hospitals or health centers has decreased.

In this health centre, we serve about 5 mothers every day,” said midwife Tigist. “We are working on achieving zero death of mothers while giving birth. But still, we are facing a shortage of medical equipment, essential medicines, and infrastructure. Also, it is a challenge to achieve a balanced distribution of midwives across the country. These are challenges of the profession.”

Investing in midwifery training

Ethiopia implemented the first Health Sector Transformation Plan (HSTP-I) from 2015/16 to 2019/20 and while significant achievements were registered, the updated plan, HSTP-11 (2021–2025) promises to focus on reaching the unreached part of the community with reproductive health emergency services by deploying midlevel health care providers to the hard to reach areas of the country. With funding from UNFPA and in collaboration with the MoH, the Midwives’ Association sends a group of midwives to conflict areas to help secure the health of mothers and infants.

2020 was designated as the International Year of the Nurse and the Midwife. Nurses and midwives play a vital role in providing health services and are central to Primary Health Care. They are often the first and only point of care in their communities. They are also part of their local community and can shape and deliver effective interventions to meet the needs of patients, families and communities. The world needs 9 million more nurses and midwives if it is to achieve UHC by 2030. Investing in Midwifery education, licensing and deployment can potentially yield a significant return on investment in terms of lives saved and costs of morbidity averted.

The Global Strategic Directions for Nursing and Midwifery report (2021 to 2025) has identified an interrelated set of policy priorities that can help countries to ensure that midwives and nurses optimally contribute to achieving UHC and other population health goals. These are in the areas of education, jobs, leadership and service delivery. For Ethiopia to properly address national health priorities like achieving the maternal mortality reduction target from the current 401 to 70/100,000 by 2030, the government should consider taking learnings from this report to determine how and where to invest in the country’s nursing and midwifery workforce and build on the gains already achieved thus far.

It is also important to put in place a framework to ensure that the results are sustained. Programmes like Nigeria’s SURE-P Maternal and Child Health Initiative which was designed to reduce Nigeria’s maternal and child mortality rate have struggled with sustainability. The programme which ended in 2015 showed for a short period that it was possible to transform PHCs in a sustainable way, to deliver better health services. However, there appeared to be no plan to carry on the project once its funding ended. Beyond investment, sustainability is therefore key to safeguarding and ensuring continuity of such programmes.

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